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Tracheoesophageal puncture for voice prosthesis placement is often used in vocal rehabilitation of patients undergoing total laryngectomy. Although its closure can occur spontaneously, some patients require a surgical procedure. We propose a surgical technique, without flap interposition, that begins with careful separation of the esophagus and trachea and identification of the site of tracheoesophageal fistula. After continuous suture closure of the esophagus, the anterior segment of the first tracheal rings is vertically incised to facilitate tracheal closure in a suture without tension. Finally, a small pectoral skin flap is made and mobilized to suture to the free edges of the sectioned tracheal rings, thus reducing the risk of tracheal stenosis. Four patients underwent this procedure with uneventful postoperative evolution and permanent closure of the fistula.

Background The main modalities for voice restoration after laryngectomy are the electrolarynx, and the tracheoesophageal puncture [Correction added on 30 January 2020 after first online publication: The preceding sentence has been revised. It originally read "The main modalities for voice restoration after laryngectomy are the electrolarynx and the tracheoesophageal puncture."]. All have limitations and new technologies may offer innovative alternatives via silent speech. Objective To describe a novel and personalized method of voice restoration using machine learning applied to electromyographic signal from articulatory muscles for the recognition of silent speech in a patient with total laryngectomy. Methods Surface electromyographic (sEMG) signals of articulatory muscles were recorded from the face and neck of a patient with total laryngectomy who was articulating words silently. These sEMG signals were then used for automatic speech recognition via machine learning. Sensor placement was tailored to the patient's unique anatomy, following radiation and surgery. A personalized wearable mask covering the sensors was designed using 3D scanning and 3D printing. Results Using seven sEMG sensors on the patient's face and neck and two grounding electrodes, we recorded EMG data while he was mouthing "Tedd" and "Ed." With data from 75 utterances for each of these words, we discriminated the sEMG signal with 86.4% accuracy using an XGBoost machine-learning model. Conclusions This pilot study demonstrates the feasibility of sEMG-based alaryngeal speech recognition, using tailored sensor placement and a personalized wearable device. Further refinement of this approach could allow translation of silently articulated speech into a synthesized voiced speech via portable devices.

BACKGROUND Among voice restoration options following laryngectomy, tracheoesophageal puncture (TEP) appears to be the most common. Currently, there is no consensus that exists with regard to the timing of performing TEP and the decision to perform a primary or secondary TEP has mostly been based on physician preference and expert opinion rather than data. OBJECTIVE OF REVIEW The objective of this study was to compare primary and secondary tracheoesophageal puncture (TEP) for voice rehabilitation in laryngectomy patients in terms of success and complication rates. TYPE OF REVIEW A systematic review of studies in the English literature was conducted for studies that directly compared primary and secondary TEP. SEARCH STRATEGY A comprehensive search of MEDLINE (January 1948-15 July 2016), EMBASE (January 1974-15 July 2016) and Web of Science (January 1970-15 July 2016) was performed. EVALUATION METHOD Two authors (KL/BAC) independently reviewed titles and abstracts, read full-text papers, extracted data and assessed quality. Disagreements were resolved via consensus. A third author (DV) resolved disagreements between reviewers when consensus was not possible. RESULTS Eleven retrospective clinical cohort studies were included. No randomised controlled trials were identified. Newcastle-Ottawa score for assessment of quality ranged from 5 to 7. Success rate was defined differently across most studies. Two studies found higher success with primary TEP compared to secondary TEP; nine studies found no difference. Voice outcomes were inconsistently measured; no difference between groups was found in 4 studies. Complication rates were divided into TEP site related, infectious and stenosis. No difference between primary and secondary TEP was found in all but one study which showed a higher rate of pharyngocutaneous fistula in the primary TEP group in salvage laryngectomy patients. CONCLUSIONS There is no robust evidence to suggest that primary TEP is associated with poorer outcomes compared to secondary TEP. A well-designed randomised controlled trial is required to appropriately answer this question.

OBJECTIVES/HYPOTHESIS Tracheoesophageal puncture (TEP) can be performed at the time of laryngectomy (primary) or postoperatively (secondary). Prior studies demonstrate safe and earlier voice acquisition and rehabilitation with primary TEP. The objectives of this study were to assess national trends in primary TEP and identify factors associated with its use. STUDY DESIGN Retrospective review. METHODS Retrospective analysis of the Nationwide Inpatient Sample (NIS) from 2010 to 2014 was performed. The NIS was queried for patients who underwent total laryngectomy (TL) (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] 30.3-30.4) and primary TEP (ICD-9-CM 31.95). Patient demographics, comorbidities, and factors known to influence the decision to perform TEP were characterized. Factors associated with primary TEP were identified by multivariable regression. RESULTS A total of 15,410 patients underwent TL during the study period. Of this cohort, 1,124 patients (7.3%) underwent primary TEP. Among patients who underwent primary TEP, 80.9% had laryngeal cancer, 16.4% had pedicled or free-flap reconstruction at the time of TL, 4.2% underwent partial pharyngectomy, and 48.0% underwent cricopharyngeal myotomy (CPM). The majority of primary TEPs were performed at urban teaching hospitals (90.6%). In multivariable regression, patients who underwent CPM were at significantly increased odds of primary TEP (odds ratio: 3.79, P

Objectives To identify differences in postoperative wound complications associated with a primary tracheoesophageal puncture (TEP) at the time of laryngectomy versus no TEP. Study Design Retrospective review of large national data set. Setting Academic and nonacademic health care facilities in United States, contributing de-identified, risk-adjusted clinical data to the American College of Surgeons National Surgical Quality Improvement Program. Subjects and Methods The National Surgical Quality Improvement Program data set for years 2006 to 2012 identified 430 patients who underwent total laryngectomy with or without a primary TEP. Patients who underwent a TEP at the time of laryngectomy (n = 68) were compared with patients who underwent laryngectomy without a TEP (n = 362). Postoperative wound complications and secondary outcomes, including medical complications and length of hospitalization, were compared between the groups. Results The incidence of "superficial" and "deep or organ space" surgical site infection, medical complications, return to the operating room, and length of hospitalization were similar between the groups. Patients in the TEP group had a higher overall wound complication rate (relative risk, 2.02; 95% CI = 1.06-3.84; attributable risk, 8.17%; number needed to harm, 12). Conclusions Performance of a primary TEP concurrent to total laryngectomy contributed to a small increase in attributable risk for overall wound complications but did not add substantial risk for "superficial" or "deep or organ space" surgical site infection, medical complications, or increased burden for resource utilization. These data may help inform patient choice and physician recommendations for primary alaryngeal speech rehabilitation.

Objectives/Hypothesis This study compares the overall durability, phonation effort, and speech quality achieved by the Blom-Singer Dual Valve prosthesis to the same characteristics achieved by the single-valve prosthesis used in a select population of total laryngectomy patients who have demonstrated single-valve prosthesis failure within 3 months of placement. Study Design Prospective phase IV study. Methods Fourteen patients who had previously experienced early valve failure using a single-valve prosthesis had a Dual Valve placed by a speech language pathologist. A total of seventeen Dual Valves were inserted during routine clinical visits for valve replacement. Time intervals from insertion to replacement of the Dual Valve, as well as the average lifespan of patients’ three previous single valves were collected. Subjective, categorical responses to speech quality and phonation effort for the Dual Valve compared to the single valve were collected on a questionnaire upon failure of the device. Results The mean duration of the single valve was 60 days, with a median of 51 days, whereas the mean duration of the Dual Valve was 164 days, with a median duration of 84 days. Both sets of data were statistically significant, with a P value of .0131. Valve life was increased in 86% of patients, with 43% experiencing greater than 150 days improvement in valve duration when using the Dual Valve. Phonation effort was increased in 14% of patients, and speech quality was not significantly affected in any patients. Conclusions In this select population, the Dual Valve offers improved durability over the single valve without sacrificing speech quality, making it a preferred prosthesis option for patients experiencing single-valve failure in less than 3 months. Level of Evidence 4. Laryngoscope, 128:422–426, 2018

Objectives/Hypothesis A total laryngectomy (TL) is performed as a primary or salvage therapy for laryngeal carcinoma. Pharyngotomy closure after TL is typically performed using manual sutures. Automatic stapling devices are routinely used in thoracoabdominal surgery, but have not been widely accepted for use in pharyngotomy closure. Previously described closed stapling techniques of pharyngeal closure do not allow direct evaluation of surgical margins and are limited to endolaryngeal disease. We describe an open technique for pharyngotomy closure using a mechanical stapling device. Study Design Retrospective review. Methods A review was conducted of 16 total laryngectomies performed from May 2008 to August 2015 utilizing an Ethicon Endopath ETS Compact-Flex 45 stapler. Results Sixteen patients (15 male, one female), mean age 69 years, received open TL (14 salvage, two primary) with endostapler pharyngeal closure and primary tracheoesophageal puncture (TEP). Surgical time averaged 218 minutes. Median time to swallowing was 4 days (range, 2–240 days) and mean hospital stay 6 days (range, 3–10 days). Fistula incidence was 31% (5/16) overall and 36% (5/14) in the postradiation patients. Conclusions Mechanical stapling is a simple method for postlaryngectomy open pharyngotomy closure. This technique allows evaluation of margins, easy primary TEP, and the opportunity for early swallowing and shorter hospital stays. In addition, it can be performed for closure of salvage laryngectomies with rates of fistula formation similar to that found in the literature using suture closure techniques. Future studies are necessary to compare oncological results and surgical complications between the open and closed stapling techniques and to traditional suture closure. Level of Evidence 4 Laryngoscope, 2016

Background We evaluated the impact of radiation, reconstruction, and timing of tracheoesophageal puncture (TEP) on complications and speech outcomes. Methods Retrospective review identified 145 patients who underwent TEP between 2003 and 2007. Results Ninety-nine patients (68%) had primary and 46 (32%) had secondary TEP, with complications occurring in 65% and 61%, respectively (p = .96). Twenty-nine patients (20%) had major complications (18 primary and 11 secondary; p = .42). Ninety-four patients (65%) had pre-TEP radiation, 39 (27%) post-TEP radiation, and 12 (8%) no radiation. With patients grouped by TEP timing and radiation history, there was no difference in complications, fluency, or TEP use. With mean 4.7-year follow-up, 82% primary and 85% secondary used TEP for primary communication (p = .66). Free-flap patients used TEP more commonly for primary communication after secondary versus primary TEP (90% vs 50%; p = .02). Conclusion Primary and secondary tracheoesophageal speakers experience similar high rates of complications. Extent of pharyngeal reconstruction, rather than radiation, may be more important in selection of TEP timing. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1765–1771, 2016

Objectives/Hypothesis Demonstrate that biofilm formation will be reduced on tracheoesophageal prostheses when vibratory stimulus is applied, compared to controls receiving no vibratory stimulus, in a dynamic in vitro model of biofilm accumulation simulating the interface across the tracheoesophageal puncture site. Study Design Prospective, randomized, controlled, crossover in university laboratory. Methods Ex vivo tracheoesophageal prostheses were obtained from university-affiliated speech language pathologists at Indiana University School of Medicine, Indianapolis. Prostheses demonstrating physical integrity and an absence of gross biofilm accumulation were utilized. Sixteen prostheses were cleansed and sterilized prior to random placement by length in two modified Robbins devices arranged in parallel. Each device was seeded with a polymicrobial oral flora on day 1 and received basal artificial salivary flow continuously with three growth medium meals daily. One device was randomly selected for vibratory stimulus, and 2 minutes of vibration was applied to each prosthesis before and after meals for 5 days. The prostheses were explanted and sonicated, and the biofilm cultured for enumeration. This process was repeated after study arm crossover. Results Tracheoesophageal prostheses in the dynamic model receiving vibratory stimulus demonstrated reduced gross biofilm accumulation and a significant biofilm colony forming unit per milliliter reduction of 5.56-fold compared to nonvibratory controls (P < 0.001). Significant reductions were observed within length subgroups. Conclusion Application of vibratory stimulus around meal times significantly reduces biofilm accumulation on tracheoesophageal prostheses in a dynamic in vitro model. Further research using this vibratory stimulus method in vivo will be required to determine if reduced biofilm accumulation correlates with longer device lifespan. Level of Evidence N/A. Laryngoscope, 2016

Background There is debate about the optimal voice restoration method and technique for patients who have undergone total laryngopharyngectomy, esophagectomy, and gastric pull-up. The purpose of this study was to report a series of patients who underwent awake, secondary tracheoesophageal puncture (TEP) after this procedure. Methods A retrospective chart review was performed at a tertiary referral center. All subjects who underwent TEP placement under transnasal esophagoscopy guidance between 2003 and 2013 were included. Results All patients underwent uncomplicated TEP in the clinic. At the time of last follow-up, all patients had functional TEP speech that they were using preferentially over an available electrolarynx. Conclusion In-office placement of secondary TEP using transnasal esophagoscopy is an efficient means of providing a conduit for voice prostheses in patients who have undergone laryngopharyngectomy with gastric pull up reconstruction. This procedure can be performed with minimal complications and with expectation of voice outcomes comparable to that seen with standard laryngectomy. © 2015 Wiley Periodicals, Inc. Head Neck, 2015

Background A new device is described for secondary tracheoesophageal puncture (TEP). We hypothesize that the device can be used to create the puncture, size, and insert the voice prosthesis in antegrade fashion in a single procedure suitable for office-based use. Methods A measurement and insertion device (MAID) was designed with the hypothesis in mind and tested on 3 pigs while they were under general anesthesia. Results The procedure was easy and successful in all 3 animals. The MAID allowed measurement of tracheoesophageal wall thickness and antegrade insertion of voice prosthesis with a single device. Transnasal esophagoscopy (TNE) allowed visualization of markings on the MAID within the esophagus to facilitate sizing. Intraesophageal visualization using TNE also enabled accurate positioning, reduced risk of posterior esophageal wall injury, and practically eliminated false passage formation. Conclusion We believe the MAID can facilitate single-stage office-based secondary TEP in postlaryngectomy patients. © 2013 Wiley Periodicals, Inc. Head Neck 36: 882–886, 2014

Objective To evaluate the indications, complications and device life of the Provox® NiD™ in a large cohort at a tertiary U. S. cancer center.

Background Gaining a new voice is one of the major aims after total laryngectomy. The objective of this study was to describe the process and results of speech rehabilitation during the first year after surgery. Methods Speech intelligibility was measured 6 months (n = 273) and 1 year (n = 225) after total laryngectomy. Results Objective (23.4 to 47.5 points, p < .0001) and subjective (51.6 to 64.7 points, p < .0001) speech intelligibility improved between 6 months and 1 year after total laryngectomy. Patients who used tracheoesophageal puncture (TEP) had the best results in speech intelligibility 6 months and 1 year after total laryngectomy. In all, 12% of the patients who used TEP initially no longer used it 1 year later. Patients who had received rehabilitation had better objective speech intelligibility than those who did not. Conclusions Speech improves considerably between 6 months and 1 year after total laryngectomy. Nonattendance of rehabilitation is associated with a worse functional outcome in speech rehabilitation. Head Neck, 35: 1583–1590, 2013

Background: Total pharyngolaryngectomy is potentially ablative surgery, resulting in compromise of some most basic functions of life, including speech and swallowing. Tracheoesophageal puncture is the gold standard for voice restoration. But it still has prosthesis-related problems. Objectives/Hypothesis: We designed a uniquely customized radial forearm free flap (RFFF), which also incorporated a region for phonation tube (PT) creation, for the dual purpose of circumferential laryngopharyngeal defect reconstruction and voice production. Methods: From August 2005 to September 2010, there were 18 male patients with late-stage hypopharyngeal cancer (HPC) or laryngeal cancer (LC) who received one-stage reconstruction with the fabricated RFFF-accompanying PT after total pharyngolaryngectomy. We recorded the phonation outcome of phonation efficacy (PE) and maximal phonation time (MPT) postoperatively within 1 month and at least 1 year after surgery. Results: Nine patients suffered from HPC and the others suffered from LC. Twelve patients received concurrent chemoradiotherapy after surgery. The follow-up time was 12 to 56 months (mean 28.7 months). There was no significant variance in the PE (79.72%, SD=21.93% vs. 62.50%, SD=39.60%, respectively; p = 0.115) and MPT (2.58 seconds, SD=1.80 vs. 2.97 seconds, SD=3.96, respectively; p = 0.878) between the first and last follow-up points, even when the patients were grouped by radiotherapy status after surgery or by disease group. Conclusions: The phonation outcome in our experience was satisfactory and it tolerated postoperative radiotherapy during at least the 12-month follow-up period.

Background. Pharyngoesophageal spasm is a known entity to cause hypertonic/failed tracheoesophageal speech and is successfully treated by botulinum toxin A injection. However, success of botulinum toxin treatment is based on the accurate localization of the pharyngoesophageal segment. Methods. A 65-year-old man who had a laryngectomy using voice prosthesis with hypertonic speech underwent ultrasonographic localization of the hypertonic pharyngoesophageal segment. The ultrasound findings were confirmed using videofluoroscopy. Under ultrasound guidance, botulinum toxin was injected into the hypertonic pharyngoesophageal segment and subsequently voice outcomes were evaluated by a speech language pathologist and the pharyngoesophageal segment was assessed by using an ultrasound scan. Results. The patient had improvement in his postinjection tracheoesophageal puncture speech. Ultrasound scan assessment of the pharyngoesophageal segment showed adequate dilation as compared to the pre-botulinum toxin injection treatment. Conclusion. Ultrasonographic localization of the hypertonic pharyngoesophageal segment and ultrasound-guided botulinum toxin injection is a simple, quick, and re latively cheap method to be used in routine practice. V C 2011 Wiley Periodicals, Inc. Head Neck 35: E122-E125, 2013

Background The purpose of this study was to show a novel technique for secondary tracheoesophageal puncture (TEP) and myotomy in patients who previously underwent total laryngectomy. Methods Fifteen patients underwent secondary TEP and 3 patients underwent myotomy. In 1 patient, both myotomy and TEP were done concurrently. A Foley catheter is nasally inserted into the esophagus with the patient under local anesthesia and the catheter balloon is inflated at the site of the planned procedure. The myotomy is performed over the inflated balloon for esophageal posterior wall protection and a voice prosthesis is inserted in a small incision made by the physician. When only myotomy is performed, the muscles over the mucosa are incised. A voice test is performed immediately. Results All patients exhibited good voice rehabilitation. One patient who had a myotomy had a penetration of the pharyngeal mucosa with immediate closure and no sequelae. Conclusion Outpatient Foley catheter–guided myotomy and secondary TEP are simple, safe, time saving, and cost-effective procedures. © 2011 Wiley Periodicals, Inc. Head Neck, 2012

Objectives: Secondary tracheoesophageal (TE) puncture standardly involves placement of a catheter at time of TE fistula creation. We explore the feasibility of placement of the prosthesis at the time of TE puncture (TEP) obviating the need for a subsequent procedure to place the prosthesis. We describe the technique and evaluate the success and potential advantages. Study Design: Retrospective chart review of consecutive patients who underwent TE prosthesis placement at the time of secondary TEP from 3/2009 to 1/2011. Methods: Fourteen patients underwent the primary TE prosthesis placement at the time of secondary puncture and were evaluated. Assessed outcomes included patient demographics, success of prosthesis placement, need for repeat procedure, early or late prosthesis dislodgement, complications, and specific voice outcomes. Results: Patient cohort included nine males, five females, with average age of 64 years. All TE prosthesis placements were successful. The 12-mm 20 F Blom-Singer Indwelling prosthesis was used in all cases. No complications occurred during prosthesis placement. Two perioperative complications occurred: one case of transient pulmonary edema from general anesthesia, one case of posterior tracheal wall swelling. The second was addressed with placement of a larger prosthesis. All patients successfully achieved good voice at an average of 4 days after the procedure (range: 1–9 days). Conclusions: This initial series of 14 consecutive patients demonstrates successful TE prosthesis placement at the time of secondary TE puncture. Functional voice was achieved in all patients with no significant immediate complications. No dislodgements occurred and no repeat procedures were required. Voice acquisition was achieved at an earlier time (4 days on average) than with traditional techniques and without the necessity of a subsequent procedure. Primary prosthesis placement at the time of secondary TE puncture is a successful option for surgical voice restoration with distinct advantages and minimal complications.

Objectives/Hypothesis: Enlargement of the tracheoesophageal puncture (TEP) results in aspiration around the voiceprosthesis (VP) and may lead to pneumonia. The primary objective was to summarize control of leakage around the VP afterconservative management of enlarged TEP.Study Design: Retrospective cohort study.Methods: This 5-year cohort included 194 patients who underwent total laryngectomy (with or without pharyngec-tomy) and TEP at the University of Texas MD Anderson Cancer Center. Control of leakage around the VP was analyzed at lastfollow-up after enlarged TEP. Adverse events were compared in patients with and without enlarged TEP.Results: The incidence of enlarged TEP was 18.6% (36 of 194, 95% confidence interval [CI]: 13.0%-24.1%). Conserva-tive methods commonly attempted in lieu of complete TEP closure included placement of an enlarged-flange VP (34 of 36,94%), temporary VP removal (14 of 36, 39%), and TEP-site injection (8 of 36, 22%). At last follow-up, conservative methodscontrolled leakage around the VP in 81% (29 of 36) of patients. Only two patients required complete TEP closure due to per-sistent leakage after enlarged TEP. Unresolved leakage was more common in patients with recurrent cancer after laryngec-tomy (P ¼ .081) and irregular TEP contour (P ¼ .003). Relative to controls without TEP enlargement, patients with enlargedTEP had a three-fold higher risk of pneumonia (relative risk: 3.4, 95% CI: 1.9–6.2) and aspiration of the prosthesis (relativerisk: 3.3, 95% CI: 0.8–14.1).Conclusions: Although the rate of enlarged TEP is relatively low, the complication significantly elevates risk of pneumo-nia. Prosthetic leakage related to TEP enlargement can often be managed conservatively to avoid complete closure of the TEP.Key Words: Tracheoesophageal puncture, total laryngectomy, enlarged tracheoesophageal puncture, risk factors.Level of Evidence: 2b.Laryngoscope, 121:1455–1461, 2011

Objectives: To determine whether postoperative complication rates and speech outcomes differ between patients undergoing primary versus secondary tracheoesophageal puncture following total laryngectomy with free flap reconstruction. Study Design: Retrospective clinical study in a tertiary academic center. Methods: Between November 2004 and June 2010, 137 patients underwent total laryngectomy or laryngopharyngectomy with pharyngeal free flap reconstruction for malignant disease. Data was collected on patient and operative demographics, early postoperative complications, speech outcomes, and predictive factors for tracheoesophageal puncture failure. Results: Thirty patients (22%) had a primary tracheoesophageal puncture performed at the time of laryngectomy, 27 patients (20%) received secondary punctures (>3 months postlaryngectomy), and 80 patients (58%) never received a puncture. Patient and operative demographics were similar between groups (P < .05), apart from proportionately more hypopharyngeal tumors in the “no puncture” group (P < .002). Similar numbers of patients in primary and secondary puncture groups achieved intelligible speech (67% vs. 71%, P = .82) and both groups reported good patient-perceived voice-related quality of life. Salvage surgery and nonpatch radial forearm free flap reconstruction both trended toward increased early postoperative complication rates (P = .09). Conclusions: There is no difference in the early postoperative complication rate for primary versus secondary tracheoesophageal puncture following total laryngectomy with concurrent free flap reconstruction. Radial forearm patch free flap reconstruction achieves good speech outcomes.

The gold standard for voice restoration after total laryngectomy is tracheoesophageal puncture (TEP). The TEP is a small surgically created fistula in the tracheoeosphageal (TE) wall that may be created at the time of the total laryngectomy (primary TEP) or later after the patient has healed from surgery (secondary TEP). A one-way valved silicone voice prosthesis (VP) is placed into the TEP. The prosthetic valve opens to allow pulmonary air into the vocal tract for vibratory sound production when the tracheostoma is occluded, but remains closed to prevent aspiration of foods/liquids during swallowing.1,2 One of the most difficult complications to manage after TEP is enlargement of the TE fistula that results in aspiration of saliva, liquid, and/or food around the VP into the trachea. Tissue changes associated with radiation, malnourishment, diabetes, smoking, and hypothyroidism may reduce elasticity and integrity of the TEP and have been implicated as potential risk factors for enlarged puncture.3–6 Development of an enlarged TEP has also been associated with acute infection or tumor recurrence.3,7 However, the actual contribution of these potential risk factors is unclear. An enlarged TEP intuitively increases the risk of pneumonia and respiratory complications due to frequent aspiration around the VP. Reduced tissue elasticity also increases the likelihood of spontaneous dislodgement of the VP and consequently the potential for aspiration of the prosthesis. Various treatments, including surgical closure of the TEP, have been proposed to mitigate the ill-effects of an enlarged TEP. Although surgical closure eliminates problems associated with leakage around the prosthesis, closure of the TEP prevents TE voice production, thus negatively impacting quality of life. Because of this, conservative methods, either surgical or nonsurgical, that aim to eliminate leakage around the VP while preserving functional TE voice, either surgical or nonsurgical but excluding complete TEP closure, are of particular interest. Although a variety of conservative treatments have been proposed, there are no clear guidelines for the conservative management of this complication. A better understanding of factors associated with enlarged TEP will lead to more uniform assessment and management of this complication, and may guide preventive efforts. For this purpose, a systematic review was conducted with the following objectives: (1) to estimate the rate of enlarged TEP causing leakage around the VP after total laryngectomy with TEP, (2) to estimate the risk of pneumonia in patients with enlarged TEP, (3) to summarize the effect of potential risk factors for enlarged TEP, and (4) to summarize the type and effectiveness of conservative treatments used to prevent leakage around the prosthesis due to enlarged TEP.

Objectives/Hypothesis: Primary tracheoesophageal puncture (TEP) is a well-described and accepted method of surgical voice restoration and is standardly completed with a catheter placement intraoperatively, which is replaced with a prosthesis at a later date. This study evaluates the intraoperative placement of the voice prosthesis at the time of the primary TEP in an effort to understand the potential advantages and disadvantages of voice prosthesis placement at the time of primary TEP completed in conjunction with total laryngectomy. Study Design: Retrospective chart review within an academic medical center. Methods: After approval by the institutional review board of the Massachusetts Eye and Ear Infirmary, a retrospective chart review was completed of all cases of primary tracheoesophageal prosthesis placement completed in conjunction with primary tracheoesophageal puncture performed at the time of total laryngectomy. Results: Thirty patients were identified, 29 of whom underwent laryngectomy for advanced laryngeal carcinoma. Twenty-eight of 29 patients received preoperative full-dose radiation therapy. Twenty-nine of 30 patients had a 20F classic Indwelling Blom-Singer prosthesis (InHealth Technologies, Carpinteria, CA) placed. One had placement of 16F Indwelling Blom-Singer prosthesis. No complications were noted with intraoperative prosthesis placement. No prostheses were dislodged in the postoperative period. Twenty-nine of 30 subjects had initial success with tracheoesophageal voice production. At 1-year follow-up, 23/30 subjects (77%) had successful voice restoration. Five failed because of recurrent disease, one subject never achieved successful voice, and one subject wanted the prosthesis removed although successful voice was achieved. Twenty-three of 25 (92%) disease-free subjects had functional voice restoration at 1-year post-total laryngectomy and primary prosthesis placement. Conclusions: This study demonstrates that the voice prosthesis can be safely and effectively placed intraoperatively at the time of primary TEP and laryngectomy. Initial voice acquisition rates were high and long-term success was well within the acceptable range. Laryngoscope, 2009

Objectives/Hypothesis: The use of a rigid esophagoscope during tracheoesophageal puncture for speaking valve insertion in laryngectomized patients may be hindered by stenosis of the esophagus, or arthritic deformation of the spine, limiting extension of the neck. To prevent complications we currently perform a blind technique in these patients with the use of a rigid hysterometer instead of the esophagoscope. Methods: Ten patients underwent secondary tracheoesophageal puncture using a rigid hysterometer. This was inserted through the mouth and gently advanced along the cervical esophagus to the level of the tracheostomy. A transverse incision was made on the posterior membranaceous wall of the trachea to enable the hysterometer to enter the tracheal lumen. The curved cannula of a Provox trocar was retrogradely inserted into the fistula following the hysterometer as a guide. After withdrawing the hysterometer, a Provox flexible guidewire was introduced into the cannula and advanced up to the oral cavity to anchor a Blom-Singer prosthesis. Withdrawal of the guidewire enabled the prosthesis to be housed in the fistula. Results: All patients had a successful surgical outcome without any intra- or postoperative complications. The resulting fistula was adequate and enabled patients to wear their prostheses without trouble and to quickly acquire an intelligible voice. Conclusions: The limited thickness allows easy advance of the hysterometer beyond esophageal stenotic tracts, and its particular curved conformation permits progression toward the level of the tracheostomy in patients who cannot assume a relaxed, extended supine position on the operating table. Laryngoscope, 2009

To compare the rate of postoperative wound-healing complications and voice fluency in primary vs secondary tracheoesophageal puncture (TEP) following chemoradiation.Between 1998 and 2005, 30 patients underwent laryngectomy after chemoradiation therapy. Twenty patients underwent primary TEP and 10 patients underwent secondary TEP. Comorbidities, postoperative complications, speech fluency, and time to speech fluency were evaluated in each patient.Pharyngocutaneous fistula (PCF) occurred in 10 of 20 (50%) patients who underwent primary TEP and in 0 of 10 (0%) patients in the secondary TEP group (P0.05). Overall, 25 of 25 (100%) patients who had placement of a tracheoesophageal prosthesis achieved fluent speech. Median time to fluency was 63 days in the primary TEP group and 125 days in the secondary TEP group.There is an increased risk of PCF in patients undergoing primary TEP compared with secondary TEP following chemoradiation. No difference in acquisition of speech fluency was identified between the two groups. Patients undergoing primary TEP achieved fluent speech 62 days sooner than their secondary TEP counterparts.

Background. Voice-related quality of life (V-RQOL) has never been studied in Indian patients. This study was planned to validate and assess V-RQOL in patients using tra- cheoesophageal puncture (TEP). Methods. A cross-sectional study was undertaken to validate V-RQOL questionnaire by testing reliability, validity, and respon- siveness. V-RQOL was assessed in patients undergoing total laryngectomy with primary TEP. Results. One hundred thirty-two patients filled 188 question- naires. Analysis was carried out on 122 patients. Reliability and validity of questionnaire were tested by Cronbach's alpha (.84- .91) and item-scale correlation (.67-.86). Median V-RQOL-Total score was 76.2 indicating excellent V-RQOL. Higher scores were observed in patients less than 50 years (82.5 vs 72.5, p 5 .08). There was no effect of time interval between laryngectomy and assessment of questionnaire on the V-RQOL scores. Conclusion. V-RQOL questionnaire can be used reliably to assess V-RQOL, which is found to be excellent in Indian patients undergoing TEP. V C 2008 Wiley Periodicals, Inc. Head Neck 31: 37-44, 2009

After total laryngectomy, voice rehabilitation can be achieved by use of voice prosthesis insertion (e.g. Blom-Singer®, Inhealth Technologies, USA; Provox®, Atos Medical, Sweden; Tracoe®, Tracoe Medical, Germany), esophageal voice or assistive digital speech device (e.g. Servox®, Servox AG, Germany). Various studies have shown that insertion of a voice prosthesis leads to superior rehabilitation results compared to other voice methods 1,2 and has become standard of care in many countries. However, insertion of voice prosthesis requires tracheo-esophageal puncture (TEP) which normally is performed during laryngectomy procedure or secondarily as an elective procedure following adjuvant therapy. Primary TEP allows almost direct visualization of the proposed TEP site and protection of the posterior esophageal wall by a rigid pharyngoscope or by the therefore introduced pharynxprotector (e.g. Provox Pharynx Protector®, Atos Medical, Sweden) In case of secondary puncture, the use of rigid scopes to protect the posterior pharyngeal wall and verify correct position of the prosthesis requires sufficient head reclination and mouth opening to ascertain adequate exposure of the upper esophagus and correct placement of the trocar. However, due to degenerative changes of the cervical spine, trismus, pharyngeal reconstruction (e.g. microvascular free tissue transfer), scar tissue formation in postirradiated patients or most often a combination of these factors, the upper esophagus sometimes cannot directly be accessed by rigid instruments. Alternative techniques for secondary TEP comprehend a special wire-guided TEP using a flexible scope 3, transnasal esophagoscopy with air insufflation 4 and a fiberoptic laryngoscope inserted in the cuffed part of an endotracheal tube for visualizing the puncture site 5. Even though these fiberoptic guided methods allow access to the upper esophagus and the puncture site can be directly visualized, safe TEP is compromised by the lack of a rigid abutment protecting the posterior esophagus wall and in some cases, air insufflation can lead to pneumomediastinum and mediastinitis due to a created “via falsa”. In our experience sufficient protection of the posterior esophagus wall is one of the key factors in preventing from possible TEP-complications, such as mediastinitis and sepsis 6. With regard to these few patients, who don’t qualify for secondary TEP by using rigid optic control, we opted for a simple, cheap and safe method to insert voice prosthesis after laryngectomy.

Objective To evaluate the safety and efficacy of early oral feeding by comparing it with feeding through primary tracheoesophageal puncture after total laryngectomy with primary pharyngeal closure. Study Design A prospective, randomized, controlled study. Methods Patients who underwent total laryngectomy with primary pharyngeal closure and who were candidates for primary voice restoration (an in whose cases primary tracheoesophageal puncture [TEP] was created) were included. After total laryngectomy, patients were randomly assigned to either the oral group (study group) or the TEP group (control group). Patients in the oral group were fed orally with a clear liquid diet on the first postoperative day, then advanced to a regular diet, whereas patients in the TEP group were fed through tracheoesophageal puncture and received nothing orally until the seventh postoperative day; then they were fed orally if fistula had not occurred. Standard criteria for discharge were used for all the patients. Results During a 3-year period, 67 patients were enrolled in the trial, and complete data were available for 65 patients (32 patients in the oral group, 33 patients in the TEP group). The two groups were similar for factors reported to influence the rate of pharyngocutaneous fistula. In three (9%) patients in the TEP group, fistula occurred on the 5th, 7th, and 14th postoperative days, respectively. Two (6.2%) fistulas occurred in the oral group on the sixth and eighth postoperative days, respectively. In patients without fistula, the mean length of hospital stay was 7.6 days (range, 4–19 d [SD = 3.1 d]) for the oral group and 8.2 days (range, 7–18 d [SD = 2.6 d) for the TEP group. There was no significant difference between two groups for either the incidence of fistula or the length of hospital stay. Conclusions Initiation of oral feeding on the first postoperative day in patients undergoing total laryngectomy with primary pharyngeal closure is a safe clinical practice. However, it does not shorten the length of hospital stay for these patients.

Secondary tracheoesophageal puncture (TEP) placement in patients with severe limitations in neck extension is challenging. Visualization of the hypopharynx with traditional rigid endoscopy may not be possible. We report using the C-MAC (Karl Storz, Tuttlingen, Germany) video laryngoscope to successfully place a secondary TEP in patient with severe radiation fibrosis at a tertiary referral center. A 59-year-old male with severe radiation fibrosis of the neck underwent total laryngectomy for a nonfunctioning larynx. His primary TEP dislodged in the early postoperative period and the patient requested secondary TEP and voice prosthesis. The result was a successful, properly positioned, placement of a secondary TEP. Videolaryngoscopy should be included in the surgeon's armamentarium of techniques to effectively and safely perform secondary TEP in anatomically difficult patients.

The authors examined the feasibility and advantages of primary tracheoesophageal puncture (TEP) with intraoperative placement of the voice prosthesis for patients undergoing laryngopharyngectomy requiring free tissue reconstruction and salivary bypass tube placement. Six patients were identified; 4 underwent total laryngopharyngectomy, and 2 underwent total laryngectomy with partial pharyngectomy. All 6 required free tissue reconstruction, and a salivary bypass tube was placed in all cases. All patients had a 20F Indwelling Blom-Singer prosthesis (InHealth Technologies, Carpinteria, California) placed. No complications were noted with intraoperative prosthesis placement. No prostheses were dislodged in the postoperative period. At 6 months, 4 patients available for evaluation had successful voice outcomes, and 3 were disease free. This study demonstrates the effectiveness of voice prosthesis placement at the time of primary TEP associated with free tissue reconstruction of a laryngopharyngeal defect with salivary bypass tube placement.

Objectives/Hypotheses Study 1: To assess the oncologic outcome following supracricoid partial laryngectomy (SCPL). Study 2: To compare the quality of life (QOL) following SCPL to total laryngectomy (TL) with tracheoesophageal puncture (TEP). Study 3: To analyze whole organ TL sections to determine the percentage of lesions amenable to SCPL. Study Design Study 1: A retrospective review of patients who underwent SCPL. Study 2: A non-randomized, prospective study using QOL instruments to compare patients who underwent either SCPL or TL. Study 3: A retrospective histopathologic study of TL specimens assessed for the possibility of performing an SCPL. Methods Study 1: Twenty-five patients with carcinoma of the larynx underwent SCPL between June 1992 and June 1999. Various rates of oncologic outcome were calculated. Study 2: Thirty-one patients participated in the QOL assessment. This included the SF-36 general health status measure, the University of Michigan Head and Neck Quality of Life (HNQOL) instrument, and the University of Michigan Voice-Related Quality of Life (VRQOL) instrument. Study 3: Ninety surgical specimens were obtained and studied from the total laryngectomy cases in the Tucker Collection. Multiple sites were evaluated for the presence of carcinoma. A computer program was written to classify whether the patient was amenable to SCPL. Results Study 1: The overall local control rate was 96% (24/25). The local control rate following SCPL with cricohyoidoepiglottopexy (CHEP) was 95% (20/21). The local control rate following SCPL with cricohyoidopexy (CHP) was 100% (4/4). Study 2: The SCPL had significantly higher domain scores than TL and TEP in the following categories for the SF-36: physical function, physical limitations, general health, vitality, social functioning, emotional limitations, and physical health summary. The significantly higher domains for the SCPL when compared with the TL and TEP for the HNQOL were eating and pain. Finally, when voice-related QOL was assessed with the V-RQOL, the domains of physical functioning and the total score were significantly better with SCPL when compared with TL and TEP. Study 3: Forty of 90 (44%) laryngeal whole organ specimens were determined to be resectable by SCPL. In 16 (18%) specimens, the patients could have undergone SCPL with CHEP and in 24 (27%) specimens the patients could have undergone SCPL with CHP. Among the 40 (44%) specimens determined to be able to have undergone SCPL, 19 were glottic (1 T1, 15 T2, 3 T3) and 21 were supraglottic (9 T2, 12 T3). Conclusions 1) A review of the literature and an analysis of the data in this study indicate that excellent local control may be expected following SCPL. 2) The QOL following SCPL, as measured by three validated QOL instruments, is superior to TL with TEP. 3) A histologic assessment of whole organ sections of TL specimens indicates that many patients who have been subjected to TL may have been candidates for SCPL. 4) If the indications and contraindications are rigorously adhered to, SCPLs are reasonable alternatives to TL in selected cases.

Objectives: The purpose of this investigation was to use videostroboscopy to study the physiologic and biomechanical effects of botulinum toxin (Botox) injection on the pharyngoesophageal segment (PES) in total laryngectomy patients with poor-quality tracheoesophageal puncture (TEP) voice caused by PES spasm. Methods: The following was a prospective study. Videostroboscopy of the PES and videotaped recordings of patients performing TEP voice tasks were conducted before and after Botox injection of the PES. Ratings of videostroboscopic and speech samples were performed by 3 blinded judges with extensive experience with this patient population. Results: Perceptually, TEP voice was more fluent and less strained after injection. Videostroboscopically, patients demonstrated improved PES volitional control and mucosal wave characteristics after Botox injection. Conclusion: Botox injection in total laryngectomy patients with poor-quality TEP voice caused by PES spasm provides improved physiologic and biomechanical function of the PES, as demonstrated for the first time videostroboscopically. These findings help explain the perceptual ratings of TEP voice improvement noted after Botox injection. Videostroboscopy can be used to provide diagnostic information to help confirm the clinical impression of PES spasm, as well as to document the effects of Botox injection on PES function. (Otolaryngol Head Neck Surg 2000;123:38-43.)

To study the complications of total laryngectomy, we evaluated 471 previously untreated patients who underwent total laryngectomy between 1980 and 1997. This series consisted of 358 patients with primary carcinoma of the larynx and 113 with carcinoma of the hypopharynx. Concurrent neck dissection was performed in 85% of patients. Complications were studied in relation to age, T and N stage, previous tracheostomy, neck dissection, margins, reconstruction, tracheoesophageal puncture, and surgeon. Complication treatment and hospitalization were also evaluated. The overall complication rate was 30.7%, with 29.2% major and 6.5% minor complications. The mortality rate was 0.6% (3/471). Pharyngocutaneous fistula was the most frequent wound complication (21%), followed by wound infection (4.2%) and hemorrhage (2.3%). Pneumonia (1.4%) and embolism (0.4%) were the most frequent medical complications. Hypopharyngeal tumors, neck dissection, and extended procedures had a significantly higher rate of complications. Complication causes, prevention, and treatment are discussed.

Background: Tracheostomal stenosis following laryngectomy is a distressing complication with major effects on patient rehabilitation. Management ranges from stenting with a prosthetic device to surgical revision. The goal is a widely patent stoma that is amenable to tracheoesophageal puncture. Objective : Review the long-term results of different methods of tracheostomal revision. Methods: Review of 43 patients with symptomatic tracheostomal stenosis. End point was ability to function with no artificial stenting of their stoma. Results: Forty-three patients underwent 55 revisions. The male-to-female ratio was 1.3:1.0. The age range was from 38 to 81 years (mean age, 59.5 y). Median time to revision was 11 months following the initial surgical procedure (range, 1-150 mo). Thirty-three patients underwent one revision; eight patients, two revisions; and two patients, three revisions. In 40 of 43 patients (93%) revision was successful. Of the last 21 patients who underwent revision, 18 had tracheoesophageal punctures placed. Fifteen developed excellent tracheoesophageal speech. The initial rates of success for these procedures were as follows: advancement flaps, 8 of 9; Z-plasty, 13 of 15 ; V-Y inset, 8 of 8; other procedures, 2 of 4; and dilation, 2 of 7 (P

Objectives/Hypothesis: Vocal rehabilitation of patients who have undergone laryngectomy is best accomplished by a tracheoesophageal puncture. Optimal function of the prosthesis requires an adequate stoma. Patients with tracheostomal stenosis require revision of the stoma if vocal rehabilitation is to take place. Revision and tracheoesophageal placement are usually done as two separate procedures. Creating a tracheoesophageal fistula at the time of stomal revision has not been addressed in the literature. Study Design: Prospective analysis and follow-up of 10 patients undergoing simultaneous tracheoesophageal puncture and stomal revision for tracheostomal stenosis between 1991 and 1996. Methods: Ten patients were reviewed. An inferiorly based V-Y advancement flap was used so as not to interfere with the tracheoesophageal puncture. All patients had received radiation prior to revision and tracheoesophageal puncture. Patients were followed for a minimum of 2 years (range, 2-6 y; median, 3 y). Results: All patients maintained an adequate stoma without stenting. Eight of ten patients (80%) developed and maintained good tracheoesophageal speech. Two patients had their speech fistulas removed. There were no intraoperative or postoperative complications. Conclusions: Creation of a tracheoesophageal fistula at the time of stomal revision allows for vocal rehabilitation with a single visit to the operating room.

This study determined the perceptions of experienced speech-language pathologists regarding current practices in the speech rehabilitation of laryngectomy patients since the introduction of the tracheoesophageal puncture–voice prosthesis technique in 1980. The sample population consisted of 151 experienced speech-language pathologists, or 43% of those who were sent questionnaires. The speech-language pathologists ranked tracheoesophageal puncture–voice prosthesis as their most preferred speech rehabilitation method and the electrolarynx as their least preferred, even though the electrolarynx continues to be the most frequently used method. Variable use of the tracheoesophageal puncture procedure by otolaryngologists was reported, with only a small portion perceived as using it routinely. About 65% of the speech-language pathologists reported that more than half of the laryngectomy patients were being given choices among speech rehabilitation methods. Nearly 50% of the speech-language pathologists reported that fewer than six speech therapy sessions were necessary with tracheoesophageal puncture patients, whereas more than 20% reported the need for 10 sessions or more. Use of manual closure of the tracheostoma by tracheoesophageal puncture patients far outweighed their use of automatic speaking valves. Most speech-language pathologists reported that they were involved in teams with otolaryngologists to determine patient suitability for tracheoesophageal puncture and to troubleshoot problems. Eighteen different categories of medical and speech production problems were reported. (Otolaryngol Head Neck Surg 1998;118:458-63.)

Background The Blom-Singer tracheoesophageal voice prosthesis has undergone continuous design modifications during the last 18 years to make it more effective, anatomically compatible, and easier to use. This evolution continues with the recent introduction of an indwelling-style voice prosthesis intended for use by individuals who are unable or disinclined to use a self-removable-style voice prosthesis. The a priori set-lifespan goal of the indwelling prosthesis was 180 days. Methods The present investigation describes the experience of 81 consecutive participants who used a total of 206 indwelling voice prostheses. Selection criteria included total laryngectomy and either primary (n = 35) or secondary (n = 46) tracheoesophageal puncture. All participants had external-beam radiotherapy either pre- or postlaryngectomy. Specifically, lifespan of the prosthesis, the effects and clinical management of fungal colonization, and participant satisfaction with this style prosthesis were studied. Results A prosthesis use rate of 90% was observed. Group 1 prostheses (without fungal colonization and without Nystatin® therapy) exhibited a lifespan significantly longer than did group 2 prostheses (with fungal colonization and prior to Nystatin® therapy) (sample mean [X] = 185.6 days versus 80.6 days; p < .05). Group 3 prostheses (following Nystatin® therapy) also exhibited a lifespan significantly longer than that of group 2 prostheses (X = 156.1 days versus 80.6 days; p < .05). Lifespans of group 1 and group 3 prostheses were not significantly different (p < .05). Conclusions The extended-wear, indwelling voice prosthesis achieved its a priori lifespan goal of 180 days (6 months) with almost uniform patient preference and without risk of increased complications. When fungal colonization was present, Nystatin® therapy significantly prolonged prosthesis lifespan. © 1997 John Wiley & Sons, Inc. Head Neck 19:487–493, 1997.

Background Tracheal stenosis can be a troubling consequence of laryngectomy. Some revision techniques disturb the posterior stoma site of a current or planned tracheoesophageal puncture (TEP). Methods A revision technique which advances the trachea out of the stoma, divides the anterior tracheal wall, and leaves the posterior tracheal wall undisturbed was designed. The paper describes the technique in detail. “Success” was defined as producing a stable, trouble-free stoma requiring no stenting; “partial success” as an improved stoma requiring some stenting; and “failure” as no improvement and continuous stenting. Results Fifteen patients underwent the procedure. Median time from laryngectomy to revision was 10 months. Preoperative to postoperative median stoma size increased from 63 mm2 to 135 mm2. Seven patients were classified as successful, six patients were partially successful, and two patients had no improvement. Conclusion The tracheal advancement flap is a safe technique for the laryngectomy patient who has undergone or might undergo voice restoration. © 1997 John Wiley & Sons, Inc. Head Neck 19: 211–215, 1997.

Background One of several causes of tracheoesophageal puncture (TEP) speech failure after total laryngectomy is disturbance in relaxation of the pharyngoesophageal (PE) segment. We introduce the use of chemical denervation of the PE segment through botulinum neurotoxin (Botox®) injection to improve TEP speech. Methods An analysis was performed on eight patients who received Botox® injections for TEP speech problems after total laryngectomy at the University of Iowa between June 4, 1991 and August 8, 1994. Retrospective chart review identified the evolution of pretreatment evaluation and injection technique which became standardized in April 1992. Prospective evaluation of results was recorded by a single speech pathologist who subjectively identified the response to Botox® in all patients and recorded pressure readings at the tracheostoma site during speech in 6 patients. Results Seven of the eight patients were noted to have improved TEP speech following injection. Five of these seven patients experienced substantially improved speech, three of whom had no ability to produce speech prior to the Botox® injection. Conclusion Botox® ingection is a safe and effective method of improving TEP speech in selected patients with disturbed relaxation of pharyngoesophageal segment. © 1997 John Wiley & Sons, Inc. Head Neck19: 92–97, 1997.

Objectives:Evaluate the use and outcomes of in-office secondary tracheoesophageal puncture (TEP) technique using trans-nasal esophagoscopy (TNE) and the Seldinger technique for placement, in a large series of patients having undergone laryngectomy and laryngopharyngectomy.Methods:A retrospective chart review at a single institution was performed on 83 subjects who underwent in-office secondary TEP procedure. Variables that were examined included disease site, staging, histology, extent of resection and reconstruction, chemoradiation, functional voice status (as assessed by speech pathologist in most recent note), and complications directly related to the procedure.Results:83 individuals from our institution met our criteria for in-office secondary TEP placement from 2006 to 2012. The overall complication rate was 2.4% (2/83). Complications included one patient with bleeding from the puncture site, and another who had closure of puncture site before initial TEP placement. At the time of most recent follow-...

Objectives:Management of laryngeal cancer has changed significantly in the past decade. Total laryngectomy (TL) has been mainly reserved for patients with recurrence or failure after chemo-radiation or patients requiring major ablative and reconstructive surgeries. Tracheoesophageal puncture (TEP) continues to be the gold standard for speech rehabilitation, yet it is unknown what the overall speech outcomes are for individuals undergoing TL in the 21st century. Our study will describe the speech rehabilitation outcomes of patients after TL in the 21st century.Methods:This is a retrospective analysis of 391 patients who underwent TL from June 2000 to February 2012 with a minimum of one year follow-up. Demographic variables and medical/surgical factors related to laryngectomy will be reviewed. Patient speech rehabilitation outcomes will be assessed and categorized into the following groups: 1) use of esophageal speech; 2) use of electrolarynx; 3) use of TEP; 4) failure to achieve functional speech; and 5) n...

Advanced laryngeal cancers frequently require total laryngectomy (TL). Some of these cancers, however, are suitable for near-total laryngectomy (NTL). We review our experience with NTL over a 14-year period and compare the functional results with those obtained over the same period using TL followed by tracheoesophageal puncture (TEP). One particular interest was the results achieved when surgery was preceded or followed by radiation therapy. From January 1980 through December 1994, 22 patients underwent NTL. The mean age of the 19 men (86.4%) and 3 women (13.6%) was 61.1 +/- 9.9 years. Follow-up ranged from 4 to 109 months, with a mean of 26.5 months. The local control rate was 90.9% (i.e., 20 of the 22 patients). Over the same time period, 11 TEPs were performed in 7 men (63.6%) and 4 women (36.4%) who had a mean age of 60.4 +/- 7.2 years. Compared with the TEP group, the patients in the NTL group had higher mean scores for swallowing, aspiration, and voice quality evaluations, although the differences were not statistically significant. Notably, 21 of 22 patients (95.5%) received preoperative or postoperative radiotherapy. Complications in the NTL group included aspiration, dilated shunt appendix, and inadequate tracheopharyngeal shunt function. Slight modifications of the NTL technique, including routine entrance into the vallecula in uninvolved larynges, the use of contralateral pyriform mucosa flaps, and the performance of an H-flap tracheostomy are described. The NTL is a sound oncologic procedure for tumors causing vocal cord fixation, and it can be successful even when postoperative radiotherapy is administered. The quality of speech, the ease of swallowing, and the incidence of aspiration are similar to those in patients who have had a TEP following TL.

Objective: 1) To determine whether tracheoesophageal puncture usage changes as a function of age. 2) To determine whether age is associated with voice deteroriation, need for repuncture, or dependence in stomal care.Method: Retrospective chart review on individuals following total laryngectomy and tracheoesophageal puncture (TEP) and minimum 1-year follow-up data after prosthesis placement. Data reviewed included demographic variables and medical/surgical factors related to laryngectomy. Outcome measures of voice deterioration, TEP use, repuncture, and change in dependent prosthesis management were compared with age.Results: Sixty-nine individuals were identified that met criteria; 58 men and 11 women. Mean age was 65 years (range, 43-88 years). Nine individuals, mean age of 70.0 years, did not use their prosthesis for speech purposes; 2 chose never to use it and the remainder became unable to speak due to further medical issues. Deterioration in speech was further noted in five individuals, mean age of 7...

Objective: Tracheoesophageal prosthesis facilitates esophageal speech in postlaryngectomy patients. The vocal prosthesis can be placed either during tracheoesophageal puncture (TEP) or, more commonly, in a delayed fashion. Our objectives were to: 1) analyze the voice outcomes and 2) compare the pain and emergency care, following primary versus delayed prosthesis placement.Method: A 2011 cohort study. A tracheoesophageal puncture occurred in conjunction with, or within 3 months of, total laryngectomy. Nine patients underwent primary and 11 patients underwent delayed prosthesis placement. The primary outcome was voice production at the first postoperative appointment. Secondary outcomes included pain and perioperative emergency room visits.Results: All patients (100%) with prostheses placed at the time of the TEP had voice production at the first postoperative clinic visit, in comparison to only 45% (5/11) of patients with prostheses placed in delayed fashion. Significant pain with vocalization occurred in ...